•Heart Diseases•Diabetes Mellitus•Substance Abuse

•HIV/AIDS•Rh Sensitization

•Anemia

I. Heart DiseasePregnancy results in increased cardiac

output, heart rate & blood volume.Normal heart is able to adapt to these

changes without difficulty.Woman with heart disease has decreased

cardiac reserve, making it more difficult for her to handle the higher workload of pregnancy.

Cardiac disease complicates about 1% of pregnancies.

1.Congenital Heart DefectsMost commonly seen in pregnant women

include: Atrial septal defect Patent ductus arteriosus Coarctation of aorta Tetralogy of fallot-impact of pregnancy depends on the specific defect.-if the heart has been surgically repaired & no evidence

of heart disease remains, the woman may undertake pregnancy with confidence.

-woman with CHD who experience cyanosis should be counseled to avoid pregnancy because the risk to mother & fetus is high.

2. Rheumatic Heart DiseaseResults from an infection (caused by the

bacteria, streptococci) known as rheumatic fever, which starts with a sore throat & leads to the scarring of one or more heart valves.

The injured valves are unable to open & close normally, resulting in obstruction to the flow of blood.

Is it possible to become pregnant?

Laboratory tests for detecting RHD:1. Throat cultures- for group A streptococcus

usually are negative by the time symptoms of rheumatic fever or RHD appear.

Isolate the organism before the initiation of antibiotic therapy to help confirm a diagnosis of streptococcal pharyngitis & to allow typing of the organism if it is isolated successfully.

2. Rapid Antigen- this test allows rapid detection of group A streptococcal antigen & allows the diagnosis of streptococcal pharyngitis & the initiation of antibiotic therapy while the patient is still in the physicians office.

3. Anti-streptococcal Antibodies-this is useful for confirming previous group

A streptococcal infection. Antibody titer should be checked @ 2-week intervals in order to detect a rising titer.

RHDCauses different types of heart valve defects.Commonly causes narrowing of the valve between

the left chambers of the heart (a condition called mitral stenosis) in women of child bearing age.

If you have mitral stenosis, you ma develop breathing difficulty(dyspnea), swelling of the ankle & feet (edema), & irregular heartbeats (arrythmia).

Can also cause abnormal leaking of blood through the valve between the left chambers of the heart ( a condition called mitral regurgitation).

General measures to be followed once you become pregnant:Make sure to keep your follow-up appointments

with your obstetrician throughout your pregnancy.Plan regular follow-up visits with your

cardiologist.Carefully follow all the recommendations of the

cardiologist.The diet should be nutritious & fluid & sodium

intake should be restricted.Take adequate rest.Watch your weight.Avoid alcohol.Stop smoking.

II. Diabetes MellitusAn endocrine disorder of carbohydrate

metabolism, results from inadequate production or use of insulin.

Insulin- produced by B cells of Islets of Langerhans in the pancreas, lowers blood glucose levels by enabling glucose to move from the blood into muscle & adipose tissue cells.

PathophysiologyPancreas- fails to produce insulin or does

not produce enough insulin to allow necessary carbohydrate metabolism.

Without insulin, glucose does not enter the cells & they become energy depleted.

Blood glucose level remains high (hyperglycemia) & the cells breakdown results in a negative nitrogen balance; fat metabolism causes ketosis.

Signs & Symptoms1. Polyuria2. Polydypsia3. Polyphagia4. weight loss

Three main types of Diabetes:1. Type I diabetes- results from the body’s

failure to produce insulin, & presently requires the person to inject insulin.

2.Type II diabetes- results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined wit an absolute insulin deficiency.

3.Gestational diabetes- is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy.

Diabetes on pregnancy outcomeThe pregnancy of a woman who has diabetes

carries a higher risk of complications, especially perinatal mortality & congenital anomalies.

Tight metabolic control reduces the risk.

Maternal Risks1. Hydramnios -increase in the volume of amniotic fluid,

occurs in 10% to 20% of pregnant women with diabetes.- a result of excessive fetal urination because of

hyperglycemia.PROM & onset of labor may occasionally be a

problem with hydramnios.2. Preeclampsia-eclampsia

- occurs more often in diabetic pregnancies than in normal pregnancies.

Fetal-neonatal risk1. Congenital anomalies

-incidence is 5% to 10% & is the major cause of death of infants born to women with diabetes.

Ex. Heart, CNS, skeletal system2. Respiratory distress syndrome

- appears to result from high levels of fetal insulin, which inhibit some fetal enzymes necessary for surfactant production.

3. Polycythemia- excessive number of RBCs-due to the diminished ability of glycosylated

hemoglobin in the mother’s blood to release oxygen.

ManagementAntepartal

Prenatal care- using a team approach to ensure an optimally healthy mother & newborn.- woman needs clear explanations & teaching to gain her cooperation in ensuring a good outcome.- the nurse-educator plays a major role in this counseling.- the woman with pregestational diabetes needs to understand what changes she can expect during pregnancy.

a. Dietary regulation- the pregnant woman with diabetes needs to

increase her caloric intake by absent 300 kcal/day.- on the first trimester she needs about 35 kcal/day

of ideal body weight. Approximately 40% to 50% of the calories came from complex, high fiber carbohydrates, 20% from protein, & 30% to 40% from fats.

- the food is divided into 3 meals & 3 snacks. Bedtime snack is the most important & should include both protein & complex carbohydrates to prevent nightime hypoglycemia.

b. Glucose monitoring- is essential to determine the need for insulin

& to assess glucose control.c. Insulin Administration

- Many women with gestational diabetes need insulin to maintain normal glucose levels. Human insulin should be used because it is the least likely to cause an allergic reaction.- given either in multiple injections or by continuous subcutaneous infusion.

Oral hypoglycemics- not rarely used

Intrapartal a. Timing of birth- most pregnant women

with diabetes, regardless of the type are allowed to go to term, with spontaneous labor.

Some clinicians opt to induce labor in a woman at term to avoid problems related to an aging placenta.

Cesarean birth maybe indicated if signs of fetal distress exist.

b. Labor management- maternal glucose levels are measured hourly to

determine insulin need.Primary goal is to prevent neonatal hypoglycemia.Often given two IV lines are used, one wit a 50%

dextrose solution & one with a saline solution.The saline solution is for piggybacking insulin or if

a bolus is needed.IV insulin is discontinued @ the end of the third

stage of labor.

Post partal ManagementFirst 24 hours postpartum, women wit pre-

existing diabetes typically require very little insulin.

They are usually managed with a sliding scale specifying dosage based on blood glucose levels.

Antihyperglycemics are contraindicated during breastfeeding.

The woman should be reassessed 6 weeks postpartum to determine whether her glucose levels are normal. If the levels are normal, she should be reassessed at a minimum of 3-year intervals.

III. Substance AbuseOccurs when a person experiences difficulties

with work, family, social relations, & health as a result of alcohol or drug use.

Drugs that are commonly misused includes:-tobacco, alcohol, cocaine, marijuana, amphetamines, barbiturates, hallucinogens, club drugs, heroin and narcotics.

Substances commonly abused during pregnancy1. Alcohol- is a central nervous system

depressant & a potent teratogen. The incidence of alcohol abuse is highest

among women ages 20 to 40 years although alcoholism is also seen in teenagers.

Chronic abuse of alcohol can undermine maternal health by causing malnutrition, bone marrow suppression, increased incidence of infections, & liver disease.

Alcohol dependence- result is that a woman may have withdrawal seizures in the intrapartal period as early as 12 to 48 hours after se stops drinking.

Delirium tremens may occur in the postpartal period & the newborn may suffer a withdrawal syndrome.

Care includes sedation to decrease irritability & tremors, seizure precautions, IV fluid therapy for hydration & preparation for an addicted newborn.

The effect of alcohol on the fetus may result in a group of signs known as fetal alcohol syndrome (FAS).

2. Cocaine & crackNearly 3% of pregnant women use illicit

drugs such as cocaine, marijuana, ecstasy, other amphetamines & heroin.

Cocaine use during pregnancy tends to affect between 1% & 5% of newborns.

Cocaine- acts as the nerve terminals to prevent the reuptake of dopamine & norepinephrine, which in turn results in vasoconstriction, tachycardia, & hypertension.

This can be taken by IV injection or by snorting the powdered form.

Crack- a form of freebase cocaine that is made up of baking soda, water, and cocaine mixed into a paste and microwaved to form a rock, can be smoked. Smoking crack leads to a quicker, more intense high because the drug is absorbed through the large surface area of the lungs.

Major adverse maternal effects of cocaine use includes: HallucinationsPulmonary edemaCerebral hemorrhageRespiratory failureHeart problems

Women who use cocaine have an increased incidence of spontaneous abortion, abruptio placentae, preterm birth, and stillbirth.

Cocaine crosses into breastmilk and may cause symptoms in the breastfeeding infant, including extreme irritability, vomiting, diarrhea, dilated pupils, and apnea.

Thus, women who continue to use cocaine after childbirth should avoid breastfeeding.

3. Marijuana- is the most widely used illicit drug among women, both pregnant and non pregnant.

More than 25% women of reproductive age admit to current or past marijuana use.

Marijuana use is associated with impaired coordination, memory, and critical thinking ability.

As a result, the pregnant women or new mother who uses marijuana may be at risk if she tries to perform tasks that require complex mental activities.

4. MDMA (Ecstasy)Methylenedioxymethamphetamine (MDMA),

better known as Ecstasy, is the most commonly used of a group of drugs referred to as club drugs, so called because they have become popular among adolescents and young adults who frequent dance clubs and “raves”.

Is taken by mouth usually as a tablet. It produces euphoria and feelings of empathy for others.

5. Heroin- is an illicit CNS depressant narcotic that alters perception and produces euphoria. It is an addictive drug that is generally administered IV.

Pregnancy in women who use heroin is considered high risk because of the increased incidence in these women of poor nutrition, iron deficiency anemia, and preeclampsia.

The fetus of a heroin-addicted woman is at increased risk for IUGR, meconium aspiration, and hypoxia.

The newborn frequently show signs of heroin addiction such as restlessness; shrill, high-pitched cry; irritability; fist sucking, vomiting, and seizures.

6. Methadone- is the most commonly used therapy for women dependent on opioids such as heroin.

Blocks withdrawal symptoms and reduces or eliminates the craving for narcotics.

Crosses the placenta and has been associated with preeclampsia, placental problems, and abnormal fetal presentation.

Prenatal exposure to methadone may result in reduced head circumference and lower birth weight.

ManagementA team approach to the care of the pregnant

woman with substance abuse problems ensures the management necessary to provide safe labor and birth for the woman and her child.

The management of drug addiction may include hospitalization if necessary to start detoxification.

Urine screening is also done regularly throughout the pregnancy if the woman has a known or suspected substance abuse problem. This testing helps to identify the type and amount of drug being abused.

Little is yet known about the effects of MDMA on pregnancy. However, the timing of ecstasy used by the pregnant woman during fetal brain development may be critical issue.

Infants exposed to ecstasy in utero may experience some of the same risks as infants exposed to other amphetamines during pregnancy, including yhe possibility of withdrawal –like symptoms such as drowsiness, jitteriness, and breathing problems.

IV. HIV/AIDSHuman immunodeficiency virus infection

is one of today’s major health concerns.

It leads to a progressive disease that ultimately results in acquired immunodeficiency syndrome (AIDS).

Women account for about 18% of cases in the U.S.

PathophysiologyHIV-1 enters the body through:

BloodBlood products

Or other body fluids such as semen, vaginal fluid and breastmilk

- It affects T-cells, thereby decreasing the body’s immune responses.

- This makes the affected person susceptible to opportunistic infections such as Pneumocystis carinii

Once infected with the virus, the individual develops antibodies that can be detected with the enzyme-linked immunosorbent assay (ELISA) & confirmed with the Western Blot test.

Can be detected within 6 mos after exposure.Asymptomatic lasting from a few mos to as

long as 17 years.Diagnosis of AIDS is made when a person is

HIV positive & has one of several specific opportunistic infections.

Maternal RisksMany women who are HIV positive choose to

avoid pregnancy because of the risk of infecting the fetus & the possibility of dying before the child is raised.

Women who become pregnant should be advised that pregnancy is not believed to accelerate the progression of HIV/AIDS, that the use of antiretroviral (ARV) therapy during pregnancy significantly reduces the risk of transmitting the HIV-1 to the fetus, and that most medications used treat HIV can be taken during the pregnancy.

Fetal-Neonatal RisksHIV/AIDS may develop in infants whose

mothers are seropositive, usuall due to perinatal transmission.

Perinatal transmission occurs transplacentally, at birth when the infant is exposed to maternal blood and vaginal secretions, via breastmilk.

ManagementCombination of ARV therapy suppresses viral

replication, helps preserve immune function, and reduces the development of resistance.

Usually consists of two nucleoside analogues reverse transcriptase inhibitors and a protease inhibitor.

Zidovudine (ZDV) is perhaps the best known of the nucleoside analogues.

Pregnant women who are currently on ARV therapy should continue their provider-recommended regimen and should receive regular, careful monitoring for pregnancy complications and possible toxicities.

Because the fetus is most susceptible to teratogenic effects during the first 10 weeks of pregnancy, and the risks of ARV therapy is not well known, women in 1st trimester might elect to delay therapy until after 12 weeks gestation.

To reduce the risk of perinatal transmission, all pregnant women with HIV infection should be offered the three-part ZDV prophylaxis regimen beginning after the first trimester.

This regimen includes:1.Oral ZDV daily2.Intravenous ZDV during labor until birth3.Oral ZDV for the infant starting 8 to 12 hours

after birth and continuing for 6 weeks.

At each prenatal visit, asymptomatic, HIV infected women are monitored for early signs of complications, such as weight loss in the second or third trimester or fever.

Each trimester the woman should have a visual examination and examination of the retina to detect such complications as toxoplasmosis.

In addition to routine prenatal testing, the woman who is HIV positive should be assessed regularly for serologic changes indicating that HIV/Aids is progressing.

A pregnancy complicated by HIV infection, even if asymptomatic, is considered high risk, and the fetus is monitored closely.

Women who are HIV positive are at increased risk for complications such as intrapartal or postpartal hemorrhage, postpartal infection, poor wound healing and infections of the genitourinary tract.

Thus, they need careful monitoring and appropriate therapy as indicated.

HIV positive woman should be cautioned against breast feeding her infant.